Provider Demographics
NPI:1043080476
Name:SHADDUCK, MISTY (LPN)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:SHADDUCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 S VAL VISTA DR # A3-618
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 N MESA DR STE 8E
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5996
Practice Address - Country:US
Practice Address - Phone:937-768-2544
Practice Address - Fax:877-991-6652
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32549101164W00000X
390200000X
PAPN301121164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program